Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO: KRS Chapter 304, 304.14-110, 304.17A-243,
304.17A-245, 25 U.S.C.
1603(13),
26 U.S.C.
36B(b)(3)(A),
26 U.S.C.
5000A,
6011,
6012,
9831,
42 U.S.C
18031,
26 C.F.R.
1.36B-2,
1.36B-3,
54.9801-6,
54.9802-4,
29 C.F.R.
2590.702-2,
42 C.F.R.
435.320,
435.603(e),
45 C.F.R.
146.123,
147.104,
147.128, Parts
155,
156
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Office of Health Data and Analytics, Division of Health
Benefit Exchange has responsibility to administer the Kentucky Health Benefit
Exchange. KRS
194A.050(1) requires the
secretary of the cabinet to promulgate administrative regulations necessary to
protect, develop, and maintain the health, personal dignity, integrity, and
sufficiency of the individual citizens of the commonwealth; to operate the
programs and fulfill the responsibilities vested in the cabinet; and to
implement programs mandated by federal law. This administrative regulation
establishes the policies and procedures relating to eligibility and enrollment
in a qualified health plan in the individual market, the operation of a Small
Business Health Options Program, and the formal review process related to SHOP
on the Kentucky Health Benefit Exchange pursuant to and in accordance with
42 U.S.C.
18031 and
45 C.F.R. Parts
155 and
156.
Section 1. Eligibility and Enrollment.
(1) An applicant shall be eligible to enroll
in a Qualified Health Plan or QHP through the Kentucky Health Benefit Exchange
or KHBE if the applicant:
(a)
1. Is a citizen or national of the United
States;
2. Is a non-citizen who is
lawfully present in the United States and is reasonably expected to become a
citizen or national; or
3. Is a
non-citizen who is lawfully present for the entire period for which enrollment
is sought;
(b) Except
for an incarceration pending a disposition of a charge, is not incarcerated;
and
(c) Meets a residency
requirement in 45 C.F.R.
155.305(a)(3).
(2) An applicant:
(a) May apply for a determination of
eligibility at any time during a year; and
(b) Shall only enroll during open enrollment
or Special Enrollment Periods or SEPs.
(3) An applicant determined eligible for
enrollment in a QHP as set forth in subsection (1) of this section shall be
eligible to enroll in a QHP during:
(a) An
open enrollment period as established in Section 5(2) of this administrative
regulation; or
(b) A SEP as
established in Sections 5(4) and 6 of this administrative regulation.
(4) An applicant shall attest to
whether or not information affecting the applicant's eligibility has changed
since the most recent eligibility determination if the applicant:
(a) Was determined eligible to enroll in a
QHP, but:
1. Did not select a QHP within the
applicable enrollment period as set forth in Section 5 or 6 of this
administrative regulation; or
2.
Was not eligible for an enrollment period; and
(b) Seeks a new enrollment period prior to
the date on which the applicant's eligibility is redetermined as established in
Section 8 of this administrative regulation.
(5) An applicant shall submit an application
for enrollment in a QHP:
(a) Via the Web site
at
www.kynect.ky.gov;
(b) By telephone;
(c) By mail; or
(d) In person.
(6)
(a) An
applicant who has a Social Security number shall provide the number to the
KHBE.
(b) An individual who is not
seeking coverage for himself or herself shall not provide a Social Security
number, except as established by Section 2(8) of this administrative
regulation.
(7) In
accordance with 45 C.F.R.
155.310(a)(2), an individual
shall not provide information regarding citizenship, status as a national, or
immigration status for an individual who is not seeking coverage for himself or
herself.
(8)
(a) Except as established by paragraph (b) of
this subsection, an applicant who requests an eligibility determination for an
insurance affordability program shall have an eligibility determination for all
insurance affordability programs.
(b) An applicant who requests an eligibility
determination for a QHP only shall not have an eligibility determination for an
insurance affordability program.
(9) An applicant shall not provide
information beyond the minimum amount necessary to determine eligibility and
enrollment through the KHBE.
Section
2. Eligibility Standards for Advanced Payments of the Premium Tax
Credit.
(1) A tax filer shall be eligible for
Advanced Payments of the Premium Tax Credit or APTC if:
(a) The tax filer is expected to have a
household income as prescribed in
45 C.F.R.
155.305(f)(1)(i) for the
benefit year for which coverage is requested; and
(b) One (1) or more applicants for whom the
tax filer expects to claim a personal exemption deduction on the tax filer's
tax return for the benefit year:
1. Meets the
requirements for eligibility for enrollment in a QHP through the KHBE as
established by Section 1 of this administrative regulation; and
2. Is not eligible for minimum essential
coverage, with the exception of coverage in the individual market, in
accordance with 26 C.F.R.
1.36B-2(a)(2) and
(c).
(2) A tax filer who is a non-citizen and
lawfully present and ineligible for Medicaid for reason of immigration status
shall be eligible for APTC if:
(a) The tax
filer meets the requirement in subsection (1)(b) of this section;
(b) The tax filer is expected to have a
household income of less than 100 percent of the Federal Poverty Level or FPL
for the benefit year for which coverage is requested; and
(c) One (1) or more applicants for whom the
tax filer expects to claim a personal exemption deduction on the tax filer's
tax return for the benefit year is:
1. A
non-citizen who is lawfully present; and
2. Not eligible for Medicaid for reason of
immigration status.
(3) A tax filer shall attest that one (1) or
more applicants for whom the tax filer attests that a personal exemption
deduction for the benefit year shall be claimed is enrolled in a QHP that is
not a catastrophic plan.
(4) A tax
filer shall not be eligible for APTC if the U.S. Department of Health and Human
Services or HHS notifies the KHBE that APTCs were made on behalf of the tax
filer or tax filer's spouse for a year in accordance with
45 C.F.R.
155.305(f)(4).
(5) An APTC amount shall be:
(a) Calculated in accordance with
26 C.F.R.
1.36B-3; and
(b) Allocated between QHPs and stand-alone
dental policies in accordance with
45 C.F.R.
155.340(e).
(6) An applicant for APTC may
accept less than the full amount of APTC for which the applicant is determined
eligible.
(7) An APTC shall be
authorized by the KHBE on behalf of a tax filer only if the KHBE obtains
necessary attestations from the tax filer that:
(a) The tax filer shall file an income tax
return for the benefit year in accordance with
26 U.S.C.
6011 and
6012;
(b) If the tax filer is married, a joint tax
return shall be filed for the benefit year;
(c) Another taxpayer shall not be able to
claim the tax filer as a dependent for the benefit year; and
(d) The tax filer shall claim a personal
exemption deduction on the tax filer's return for the applicants identified as
members of the tax filer's family, including the tax filer and the spouse of
the tax filer, in accordance with
45 C.F.R.
155.305(f)(4).
(8) An application filer who is
not an applicant shall provide the Social Security number of a tax filer only
if the applicant attests that the tax filer:
(a) Has a Social Security number;
and
(b) Filed a tax return for the
year for which tax data would be utilized for verification of household income
and family size.
(9) The
effective date for APTC shall be:
(a) For an
initial eligibility determination, in accordance with the dates established by
Section 5(1), (2), (3), and (4) of this administrative regulation, as
applicable; and
(b) For a
redetermination, in accordance with the dates established by
45 C.F.R.
155.330(f) and
155.335(i), as
applicable.
(10) An
employer may be notified of an employee's eligibility for APTC in accordance
with 45 C.F.R.
155.310(h).
Section 3. Eligibility Standards
for Cost Sharing Reductions.
(1) An applicant
shall be eligible for Cost Sharing Reductions or CSRs if the applicant:
(a) Meets the eligibility requirements for
enrollment in a QHP as set forth in Section 1 of this administrative
regulation;
(b) Meets the
requirements for APTC as set forth in Section 2 of this administrative
regulation;
(c) Is expected to have
a household income that does not exceed the amount established by
45 C.F.R.
155.305(g)(1)(i)(C) for the
benefit year for which coverage is requested; and
(d) Except for an enrollee who is an Indian,
enrolls in a silver level QHP through the KHBE.
(2) An eligibility determination for CSRs
shall be based on the categories as described in
45 C.F.R.
155.305(g)(2).
(3) If two (2) or more individuals enrolled
in the individual market under a single policy would be eligible for different
cost sharing amounts if enrolled in separate policies, the individuals under
the single policy shall be found by the KHBE to be collectively eligible only
for the last category listed in
45 C.F.R.
155.305(g)(3) for which all
the individuals covered by the policy would be eligible.
(4) The effective date for CSRs shall be:
(a) For an initial eligibility determination,
in accordance with the dates established by Section 5(1), (2), (3), and (4) of
this administrative regulation, as applicable; and
(b) For a redetermination, in accordance with
the dates established by 45
C.F.R. 155.330(f) and
45 C.F.R.
155.335(i), as
applicable.
(5) An
employer shall be notified of an employee's eligibility for CSRs in accordance
with 45 C.F.R.
155.310(h).
Section 4. Verification Processes.
(1) Verification of eligibility for an
applicant seeking enrollment in a QHP shall be performed in accordance with:
(a)
45 C.F.R.
155.315; and
(b) The Kentucky QHP/APTC Eligibility
Verification Plan.
(2)
Verification of eligibility for an applicant or tax filer who requests an
eligibility determination for an insurance affordability program shall be in
accordance with:
(a)
45 C.F.R.
155.320; and
(b) The Kentucky QHP/APTC Eligibility
Verification Plan.
Section
5. QHP Enrollment Periods and Effective Dates of Coverage.
(1) A qualified individual shall enroll in a
QHP or an enrollee may change from one (1) QHP to another QHP during an open
enrollment period.
(2) The
timeframe for an open enrollment period shall be established by the secretary
of the Cabinet for Health and Family Services.
(3) A qualified individual or enrollee who
selects a QHP during an open enrollment period shall have an effective date of
coverage of:
(a) January 1, if a QHP selection
is made on or before December 15 of the previous year;
(b) If after December 15, the first day of
the following month, if a QHP selection is made between the first and the
fifteenth of a month; or
(c) If
after December 15, the first day of the second following month, if a QHP
selection is made between the sixteenth and last day of a month.
(4)
(a) A qualified individual shall enroll in a
QHP or an enrollee may change from one (1) QHP to another QHP during a SEP as
established by Section 6 of this administrative regulation.
(b) A qualified individual or an enrollee who
selects a QHP during a SEP shall have an effective date of coverage as set
forth in Section 6 of this administrative regulation.
(5) An initial enrollment in a QHP shall not
be effective until the first month's premium is received by the QHP
issuer.
(6) A qualified individual
may enroll in a Stand-Alone Dental Plan (SADP) outside the QHP Enrollment
without an SEP. If the SADP is selected:
(a)
On or before the 15th of the month, the effective date will be the first day of
the following month.
(b) After the
15th of the month, the effective date will be the first day of the second
following month.
Section
6. Special Enrollment Periods.
(1) Except as established by subsection (3)
of this section, a qualified individual or enrollee shall have sixty (60) days
from the date of a qualifying event as set forth in subsection (2) of this
section to select a QHP.
(2) A
qualified individual may enroll in a QHP or an enrollee or a dependent of an
enrollee may change QHPs during a SEP if:
(a)
The qualified individual or a dependent of the qualified individual:
1. Loses minimum essential
coverage;
2. Is enrolled in any
non-calendar year group health plan, individual health insurance coverage, or
qualified small employer reimbursement arrangement even if the qualified
individual or his or her dependent has the option to renew or reenroll in the
coverage;
3. Loses
pregnancy-related coverage described in
45 C.F.R.
155.420(d)(1)(iii);
4. Loses medically needy coverage as
described under 42 C.F.R.
435.320 only once per calendar year;
or
5. Is enrolled in coverage under
26 C.F.R.
54.9801-6(a)(3)(i) through
(iii) for which an employer is paying all or
part of the premiums and the employer ceases its contributions;
(b) The qualified individual gains
a dependent or becomes a dependent through marriage, birth, adoption, placement
for adoption, placement in foster care, a child support order, or other court
order;
(c) The qualified
individual, or a dependent of the qualified individual, who was not previously
a citizen, national, or lawfully present gains status as a citizen, national,
or lawfully present;
(d) The
enrollee is determined newly eligible or newly ineligible for APTC;
(e) The enrollee or a dependent of the
enrollee becomes newly eligible for CSRs and is not enrolled in a silver-level
QHP;
(f) The enrollee or a
dependent of the enrollee becomes newly ineligible for CSRs and is enrolled in
a silver-level QHP;
(g) The
qualified individual or a dependent of the qualified individual who is enrolled
in qualifying coverage in an employer-sponsored plan is determined newly
eligible for APTC in part on a finding that the individual shall no longer be
eligible for qualifying coverage in the employer-sponsored plan in the next
sixty (60) days and is allowed to terminate existing coverage;
(h) The qualified individual or enrollee or a
dependent of the qualified individual or the enrollee:
1. Gains access to new QHPs as a result of a
permanent move; and
2. Had minimum
essential coverage or MEC for one (1) or more days during the sixty (60) days
preceding the date of the permanent move;
(i) The qualified individual is an Indian who
may enroll in a QHP or change from one (1) QHP to another QHP one (1) time per
month;
(j) The qualified individual
is or becomes a dependent of an Indian and is enrolled or is enrolling in a QHP
on the same application as the Indian, and may change from one (1) QHP to
another QHP one (1) time per month, at the same time as the Indian;
(k) The qualified individual or enrollee or a
dependent of the qualified individual or enrollee is no longer
incarcerated;
(l) The qualified
individual or enrollee, or a dependent of the qualified individual or enrollee:
1. Gains access to an individual Health
Reimbursement Arrangement or HRA; or
2. Is newly provided a Qualified Small
Employer Health Reimbursement Arrangement or QSEHRA;
(m) The plan in which the enrollee or a
dependent of the enrollee is enrolled is decertified by the division;
(n) The enrollee loses a dependent or is no
longer considered a dependent through divorce or legal separation;
(o) The enrollee or a dependent of the
enrollee dies;
(p) The qualified
individual or enrollee:
1. Is a victim of
domestic abuse or spousal abandonment as defined by
26 C.F.R.
1.36B-2, or a dependent of the qualified
individual or enrollee, or an unmarried victim of domestic abuse or spousal
abandonment residing within the same household as the qualified individual or
enrollee;
2. Is enrolled in MEC;
and
3. Sought to enroll in coverage
separate from the perpetrator of abuse or abandonment;
(q) The qualified individual or enrollee:
1. Is a dependent of an individual described
in paragraph (i) of this subsection;
2. Is on the same application as the
individual described in paragraph (i) of this subsection; and
3. Enrolls at the same time as the individual
described in paragraph (i) of this subsection;
(r) The qualified individual or enrollee:
1. Applies for coverage during:
a. An annual open enrollment period;
or
b. If there is a qualifying
event, a SEP; and
2. Is
determined ineligible for Medicaid or the Kentucky Children's Health Insurance
Program or KCHIP:
a. After open enrollment has
ended; or
b. More than sixty (60)
days after the qualifying event;
(s) The qualified individual or dependent of
the qualified individual enrolls or fails to enroll in a QHP due to an error,
misrepresentation, or inaction of an officer, employee, or representative of
the KHBE;
(t) The enrollee or
dependent of the enrollee demonstrates to the KHBE that the QHP in which the
enrollee or the dependent of the enrollee is enrolled substantially violated a
provision of its contract in relation to the enrollee or dependent;
(u) The qualified individual or enrollee, or
a dependent of the qualified individual or enrollee, demonstrates to the KHBE
that a material error related to a plan benefit, service area, or premium
influenced the qualified individual's or enrollee's decision to purchase a QHP
though KHBE. Material errors may include any incorrect premium, copay,
co-insurance, or deductible amount, as well as services covered or providers
included in network;
(v) The
qualified individual:
1.
a. Was previously ineligible for APTC because
of a household income below 100 percent of the FPL; and
b. Was ineligible for Medicaid due to living
in a non-Medicaid expansion state during the same timeframe; and
2. Either:
a. Experiences a change in household income;
or
b. Makes a permanent move to the
Commonwealth of Kentucky resulting in the individual becoming newly eligible
for APTC;
(w)
The qualified individual or a dependent of the qualified individual:
1. Experiences a decrease in household
income;
2. Is newly determined
eligible by the KHBE for APTC; and
3. Had MEC for one (1) or more days during
the sixty (60) days preceding the date of the change in household income;
or
(x) The qualified
individual or a dependent of the qualified individual meets other exceptional
circumstances as defined by 45 C.F.R.
155.420(d)(9).
(3) The date of the triggering
event for the loss of MEC shall be:
(a) For a
decertification of a QHP as set forth in
900 KAR 10:115, the date of the
notice of decertification;
(b) For
an event described in subsection (2)(a)2. of this section, the last day of the
plan year;
(c) For an event
described in subsection (2)(a)5. of this section, the last day of the period
for which COBRA continuation coverage is paid for, in part or in full, by an
employer; or
(d) For all other
cases, the date the qualified individual or dependent of the qualified
individual loses eligibility for minimum essential coverage.
(4) Loss of MEC shall include
those circumstances described in
26 C.F.R.
54.9801-6(a)(3)(i) through
(iii).
(5) Loss of MEC shall not include termination
or loss due to:
(a) Failure to pay premiums on
a timely basis; or
(b) A situation
allowing for a rescission as established by
45 C.F.R.
147.128.
(6) Except as established by subsection (7),
(8), or (9) of this section, a qualified individual or enrollee who selects a
QHP during a SEP shall have an effective date of coverage of:
(a) The first day of the following month for
a selection made between the first and the fifteenth day of any month;
or
(b) The first day of the second
following month for a selection made between the sixteenth and last day of any
month.
(7) A qualified
individual or enrollee who selects a QHP:
(a)
For a birth, adoption, placement for an adoption, placement in foster care, or
child support or other court order, shall have an effective date of coverage of
either:
1. The date of the birth, adoption,
placement for adoption, placement in foster care, or effective date of court
order; or
2. If the qualified
individual or enrollee elects:
a. The first of
the month following plan selection; or
b. In accordance with subsection (6) of this
section;
(b)
For a marriage, shall have an effective date of coverage of the first day of
the month following plan selection;
(c) For a loss of coverage as described in
subsection (2)(a) of this section, for a gain of access to a new QHP as a
result of a permanent move as described in subsection (2)(h) of this section,
or for being newly eligible for enrollment in a QHP as described in subsection
(2)(c) or (2)(k) of this section, if:
1. The
plan selection is made on or before the day of the triggering event, shall have
a coverage effective date of the first day of the month following the
triggering event; or
2. The plan
selection is made after the date of the triggering event, shall have a coverage
effective date in accordance with this subsection; or
(d) For a death as described in subsection
(2)(o) of this section, shall have a coverage effective date:
1. Of the first day of the month following a
plan selection; or
2. In accordance
with paragraph (c) of this subsection.
(8) A qualified individual, enrollee, or
dependent of the qualified individual or enrollee who selects a QHP as
described in subsection (2)(g) of this section shall have a coverage effective
date:
(a) If the plan selection is made before
the day of the triggering event:
1. On the
first day of the month following the triggering event; or
2. If the triggering event is on the first
day of a month, on the date of the triggering event; or
(b) If the plan selection is made on or after
the day of the triggering event, on the first day of the month following plan
selection.
(9) A
qualified individual or enrollee who selects a QHP in accordance with
subsection (2)(a)4.,(r), (s), (t), (u),or (v) of this section shall have a
coverage effective date based on the circumstances of the SEP.
(10)
(a) An
individual described in subsection (2)(g) of this section may access a SEP
sixty (60) days prior to the end of the individual's qualifying coverage in the
employer-sponsored plan.
(b) An
individual who accesses a SEP as set forth in paragraph (a) of this subsection
shall not be eligible for APTCs until the end of the individual's qualifying
coverage through the eligible employer-sponsored plan.
(11) If an existing enrollee becomes newly
eligible for CSRs and is not enrolled in a silver plan, the enrollee may choose
a silver plan.
(12) If an enrollee
and a dependent of an enrollee become newly ineligible for CSRs and are
enrolled in a silver-level QHP, the enrollee may change to a QHP one (1) metal
level higher or lower.
(13) If an
enrollee gains a dependent due to marriage, birth, adoption, foster care, or
court order, the enrollee shall:
(a) Not
change plans; and
(b) Either:
1. Add the new dependent to the enrollee's
current enrollment; or
2. Enroll
the new dependent in a plan of any plan category.
(14) Except for the qualifying
events established by subsection (2)(i), (l), (p), (u), and (v) of this section
and the events described in subsections (11), (12), and (13) of this section:
(a) If an enrollee qualifies for a SEP, the
enrollee may change to a QHP within the same level of coverage;
(b) If a dependent of an enrollee qualifies
for a SEP and the enrollee does not also qualify for a SEP, the enrollee shall
add the dependent to the enrollee's current QHP; or
(c) If a qualified individual who is not an
enrollee qualifies for a SEP and has a dependent who is an enrollee who does
not qualify for a SEP, the qualified individual shall be added to the
dependent's current QHP.
(15) For a qualified individual, enrollee, or
dependent described in subsection (2)(l) of this section, the triggering event
shall be:
(a) The first day on which coverage
for the qualified individual, enrollee, or dependent under the individual
coverage HRA can take effect; or
(b) The first day on which coverage under the
QSEHRA takes effect.
(16) A qualified individual, enrollee, or
dependent described in subsection (2)(l) of this section shall:
(a) Qualify for a SEP regardless of whether
they were previously offered or enrolled in an individual HRA or previously
provided a QSEHRA, if:
1. The qualified
individual, enrollee, or dependent is not enrolled in the individual coverage
HRA; or
2. The qualified
individual, enrollee, or dependent is not covered by the QSEHRA on the day
immediately prior to the triggering event; and
(b)
1. Have
sixty (60) days before the triggering event to select a QHP; or
2. Have sixty (60) days before or after the
triggering event if the HRA or QSEHRA was not required to provide the notice
described in 45 C.F.R.
146.123(c)(6),
26 C.F.R.
54.9802-4(c)(6), and
29 C.F.R.
2590.702-2(c)(6) or
26 U.S.C.
9831(d)(4).
(17) A qualified
individual or enrollee, or the dependent of a qualified individual or enrollee,
who is eligible for advance payments of the premium tax credit, and whose
household income, as defined in
26 C.F.R.
1.36B-1(e), is expected to
be no greater than 150 percent of the Federal poverty level, may enroll in a
QHP or change from one QHP to another one (1) time per month during periods of
time when the applicable taxpayer's applicable percentage for purposes of
calculating the premium assistance amount, as defined in
26 U.S.C.
36B(b)(3)(A), is set at
zero.
(18) If a qualified
individual, enrollee, or dependent of a qualified individual or an enrollee did
not receive timely notice of an event that triggers eligibility for a SEP under
this section, and otherwise was reasonably unaware that a triggering event
described in this section occurred, the qualified individual, enrollee, or his
or her dependent shall have sixty (60) days from the date that he or she knew,
or reasonably should have known, of the occurrence of the triggering
event.
(19) A qualified individual,
enrollee, or dependent of a qualified individual or enrollee, described in
45 C.F.R.
155.420 as being eligible for a SEP not
specified in this section of this administrative regulation shall be eligible
for a SEP.
(20) For purposes of
this section, a qualified individual, enrollee, or dependent of a qualified
individual or enrollee shall be:
(a) Eligible
for APTC if eligibility is for an amount greater than zero dollars per month;
or
(b) Ineligible for APTC if
eligible for a maximum of zero dollars per month.
Section 7. Verifications for
Special Enrollment Periods.
(1) KHBE shall
conduct pre-enrollment verification of newly enrolling individuals as
established by this section.
(2) A
QHP enrollment for an individual subject to verification shall not be submitted
to the issuer pending verification for a SEP.
(3) For an enrollment subject to verification
as described in this section, a new enrollee shall have thirty (30) days from
the date of plan selection to provide requested documentation.
(4) A qualifying individual described in
Section 6(2)(h) of this administrative regulation shall provide proof of:
(a) A permanent move during the past sixty
(60) days; and
(b) Either:
1. Having had MEC for one (1) or more days
during the sixty (60) days preceding the date of the qualifying event;
or
2. Having:
a. Lived in a foreign county or in a US
territory for one (1) or more days during the sixty (60) days preceding the
qualifying event;
b. Lived in a
service area where no qualified health plan was available through KHBE for one
(1) or more days during the sixty (60) days preceding the qualifying event or
their most recent open enrollment or SEP; or
c. Status as an Indian.
(5) For a marriage, as
described in Section 6(2)(b) of this administrative regulation, a qualified
individual shall provide proof of marriage during the past sixty (60)
days.
(6) Other than as described
in subsections (4) and (5) of this section, a qualified individual described in
Section 6(2)(b) of this administrative regulation shall provide proof of:
(a) The qualifying event during the past
sixty (60) days; and
(b) Either:
1. Having MEC as described in Section 6(2)(a)
of this administrative regulation for one (1) or more days during the sixty
(60) days preceding the date of the qualifying event; or
2. Meeting the requirements in subsection
(4)(b) of this section.
(7) For a loss of MEC as described in Section
6(2)(a) of this administrative regulation, a qualified individual shall provide
proof of coverage for one (1) or more days during the past sixty (60)
days.
(8) SEP verification shall
not impact an enrollee's effective date of coverage except as provided in
45 C.F.R.
155.400(e)(1)(iii).
Section 8. Eligibility
Redetermination During a Benefit Year.
(1)
Eligibility shall be redetermined for an enrollee during a benefit year if the
KHBE receives and verifies:
(a) New
information reported by an enrollee; or
(b) Updated information obtained in
accordance with 45 C.F.R.
155.330(d).
(2) Except as established by
subsection (3) of this section, an enrollee or an application filer, on behalf
of an enrollee, shall report within thirty (30) days:
(a) A change related to an eligibility
standard in Section 1, 2, 3, 9, or 10 of this administrative regulation;
and
(b) Via a method described in
Section 1(5) of this administrative regulation.
(3) An enrollee who did not request an
eligibility determination for an insurance affordability program shall not
report a change related to income.
(4) If new information provided by an
enrollee in accordance with subsection (1)(a) of this section is verified:
(a) Eligibility shall be redetermined in
accordance with the standards in Section 1, 2, 3, 9, or 10 of this
administrative regulation;
(b) The
enrollee shall be notified of the redetermination in accordance with the
requirements in 45 C.F.R.
155.310(g); and
(c) If applicable, the enrollee's employer
shall be notified in accordance with the requirement established by
45 C.F.R.
155.310(h).
(5) If updated information
obtained in accordance with subsection (1)(b) of this section regarding death
or related to eligibility not regarding income, family size, or family
composition is identified, an enrollee shall:
(a) Be notified by the KHBE of:
1. The updated information; and
2. The projected enrollees' eligibility
determination after consideration of the information; and
(b) Have thirty (30) days from the date of
the notice in paragraph (a) of this subsection to notify the KHBE if the
information is inaccurate.
(6) If an enrollee responds to the notice in
subsection (5)(a) of this section, contesting the updated information in the
notice, the KHBE shall proceed in accordance with
45 C.F.R.
155.315(f).
(7) If an enrollee does not respond to the
notice in subsection (5)(a) of this section within the thirty (30) day
timeframe specified in subsection (5)(b) of this section, the KHBE shall:
(a) Redetermine eligibility in accordance
with the standard in Section 1, 2, 3, 9, or 10 of this administrative
regulation; and
(b) Notify the
enrollee regarding the determination in accordance with the requirements
established by 45 C.F.R.
155.310(g).
(8) With the exception of
information regarding death, if updated information regarding income, family
size, or family composition is identified, an enrollee shall:
(a) Be notified by the KHBE of:
1. The updated information regarding income,
family size, and family composition obtained in accordance with subsection
(1)(b) of this section; and
2. The
projected eligibility determination after consideration of the information;
and
(b) Have thirty (30)
days from the date of the notice to:
1.
Confirm the updated information; or
2. Provide additional information.
(9) If the enrollee
responds to the notice in subsection (8)(a) of this section by confirming the
updated information, the KHBE shall:
(a)
Redetermine the enrollee's eligibility in accordance with Section 1, 2, 3, 9,
or 10 of this administrative regulation; and
(b) Notify the enrollee regarding the
determination in accordance with the requirements established by
45 C.F.R.
155.310(g).
(10) If the enrollee does not
respond to the notice in subsection (8)(a) of this section within the thirty
(30) day timeframe established by subsection (8)(b) of this section, the KHBE
shall maintain the enrollee's existing eligibility determination without
considering the updated information in subsection (8)(a) of this
section.
(11) If the enrollee
responds with more updated information, the KHBE shall verify the updated
information in accordance with
45 C.F.R.
155.315 and
155.320.
(12) The effective date of a change resulting
from a redetermination pursuant to this section shall be in accordance with
45 C.F.R.
155.330(f).
(13) The amount of an APTC or eligibility for
a CSR as a result of an eligibility redetermination in accordance with this
section shall be recalculated in accordance with
45 C.F.R.
155.330(g).
Section 9. Annual Eligibility
Redetermination.
(1) A qualified individual
shall:
(a) Have an annual redetermination of
eligibility; and
(b) Be sent a
notice of the annual redetermination that includes:
1. The data obtained under subsection (2) of
this section;
2. The data used in
the qualified individual's most recent eligibility determination; and
3. The projected eligibility determination
for the following year, after considering the information in subparagraph 1. of
this paragraph.
(2)
(a) A
qualified individual requesting an eligibility determination for an insurance
affordability program shall authorize the release of updated tax return
information, data regarding Social Security benefits, and data regarding
MAGI-based income, as defined by
42 C.F.R.
435.603(e) and as described
in 45 C.F.R.
155.320(c)(1), for use in
the qualified individual's eligibility redetermination.
(b) Eligibility shall not be redetermined for
a qualified individual requesting an eligibility determination for an insurance
affordability program who does not authorize the release of updated tax return
information.
(3) A
qualified individual may authorize the release of tax return information for a
period of no more than five (5) years based on a single authorization, if the
authorization permits the qualified individual to:
(a)
1.
Decline to authorize the release of updated tax return information;
or
2. Authorize the release of
updated tax return information for fewer than five (5) years; and
(b) Discontinue, change, or renew
the authorization at any time.
(4) A qualified individual, an application
filer, or an authorized representative, on behalf of the enrollee, shall report
any changes with respect to the information listed in the notice described in
subsection (1)(b) of this section:
(a) Within
thirty (30) days from the date of the notice; and
(b) Via a method listed in Section 1(5) of
this administrative regulation.
(5) Any information reported by a qualified
individual under subsection (4) of this section shall be verified as set forth
in Section 4 of this administrative regulation.
(6) For a qualified individual who fails to
act on the notice described in subsection (1)(b) of this section within the
thirty (30) day period established by subsection (4) of this section,
eligibility shall be redetermined as set forth in subsection (7)(a) of this
section.
(7)
(a) After the thirty (30) day period
established by subsection (4) of this section:
1. Eligibility of a qualified individual
shall be redetermined in accordance with the standards in Section 1, 2, 3, 9,
or 10 of this administrative regulation using the information provided in the
notice, as supplemented with any information reported by the qualified
individual verified in accordance with Section 4 of this administrative
regulation;
2. The qualified
individual shall be notified in accordance with the requirements in
45 C.F.R.
155.310(g); and
3. If applicable, the qualified individual's
employer shall be notified in accordance with
45 C.F.R.
155.310(h).
(b) If a qualified individual
reports a change with respect to the information provided in the notice
established by subsection (1)(b) of this section that has not been verified by
the KHBE as of the end of the thirty (30) day period established by subsection
(4) of this section, eligibility shall be redetermined after verification in
accordance with Section 4 of this administrative regulation.
(8) The effective date of a
redetermination in accordance with this section shall be the later of:
(a) The first day of the coverage year
following the year in which the notice in subsection (1)(b) of this section is
issued to the qualified individual; or
(b) The date determined in accordance with
45 C.F.R.
155.330(f)(1).
(9) If an enrollee remains
eligible for coverage in a QHP upon annual redetermination and has not
terminated coverage from the QHP in accordance with Section 10 of this
administrative regulation, the enrollee shall:
(a) Remain in the QHP selected the previous
year that may include modifications that shall be approved by the Department of
Insurance; or
(b) Be enrolled by
KHBE in a QHP that is substantially similar that shall be approved by the
Department of Insurance.
(10) Eligibility shall not be redetermined if
a qualified individual was redetermined eligible in accordance with this
section during the prior year, and the qualified individual was not enrolled in
a QHP when the redetermination was made and has not enrolled in a QHP since the
redetermination.
Section
10. Eligibility to Enroll in a QHP that is a Catastrophic Plan.
(1) In addition to the requirements in
Section 1 of this administrative regulation, to enroll in a QHP that is a
catastrophic plan, an applicant shall:
(a)
Not have attained the age of thirty (30) before the beginning of the plan year;
or
(b) Have a certificate of
exemption from the shared responsibility payment issued by the KHBE or HHS for
a plan year in accordance with:
1.
26 U.S.C.
5000A(e)(1); or
2.
26 U.S.C.
5000A(e)(5).
(2) Verification
related to eligibility for enrollment in a QHP that is a catastrophic plan
shall be in accordance with 45 C.F.R.
155.315(j).
Section 11. Special Eligibility
Standards and Processes for Indians.
(1) An
applicant who is an Indian, as defined by
25 U.S.C.
1603(13), shall be eligible
for the special cost sharing described in
45 C.F.R.
155.350(b) if the applicant:
(a) Meets the requirements established by
45 C.F.R.
155.305(a) and
(f);
(b) Is expected to have a household income
that does not exceed the amount established by
45 C.F.R.
305(g)(3)(vi) for the
benefit year for which coverage is requested; and
(c) Enrolls in a QHP through the
KHBE.
(2) An applicant
who is an Indian shall have an eligibility determination for the special cost
sharing described in 45
C.F.R. 155.350(b) without
requesting an eligibility determination for an insurance affordability
program.
Section 12.
Eligibility Determination and Notification Standards.
(1) Eligibility shall be determined in
accordance with 45 C.F.R.
155.310(e).
(2) Notifications regarding eligibility
determinations shall be made in accordance with
45 C.F.R.
155.310(g).
Section 13. Termination of
Coverage.
(1) An enrollee, including an
enrollee who has obtained other MEC, may terminate coverage in a QHP by
submitting a request:
(a) Via the Web site at
www.kynect.ky.gov;
(b) By telephone;
(c) To the QHP issuer;
(d) By mail; or
(e) In person.
(2) An enrollee in a QHP may choose to remain
in a QHP without financial assistance if the enrollee:
(a)
1. Has
been identified as eligible for other MEC through the data matching described
in 45 C.F.R.
155.330(d); or
2. Has been identified as eligible for
Medicaid, KCHIP, or Medicare and has granted prior permission to KHBE;
and
(b) Does not request
termination in accordance with subsection (1) of this section.
(3) The last day of coverage of an
enrollee who terminates coverage in accordance with subsection (1) of this
section shall be:
(a) The termination date
requested by the enrollee if the enrollee provides reasonable notice in
accordance with subsection (7) of this section;
(b) Fourteen (14) days after the termination
is requested by the enrollee, if the enrollee does not provide reasonable
notice in accordance with subsection (7) of this section;
(c) A date determined by the issuer of an
enrollee's QHP if the issuer is able to terminate coverage in fewer than
fourteen (14) days and the enrollee requests an earlier termination effective
date; or
(d) If the enrollee is
newly eligible for Medicaid or KCHIP, the day before coverage in Medicaid or
KCHIP begins.
(4) An
enrollee's health coverage shall be terminated by an issuer if:
(a) The enrollee is no longer eligible for
coverage in a QHP through the KHBE;
(b) The enrollee has failed to pay a premium
and:
1. A three (3) month grace period
required for an individual receiving an APTC has been exhausted as described in
45 C.F.R.
156.270(g); or
2. A thirty (30) day grace period required by
KRS
304.17A-243 for an individual not receiving
an APTC has been exhausted;
(c) The enrollee's coverage is rescinded in
accordance with 45 C.F.R.
147.128 or
KRS
304.14-110;
(d) The enrollee is enrolled in a QHP that:
1. Has been decertified pursuant to
900 KAR 10:115; or
2. Has withdrawn from participation in the
KHBE; or
(e) The
enrollee changes from one (1) QHP to another during an open enrollment period
or SEP in accordance with Section 5 or 6 of this administrative
regulation.
(5) The last
day of coverage of an enrollee shall be:
(a)
If terminated in accordance with subsection (4)(a) of this section, the last
day of the month following the month in which the notice described in
subsection (7) of this section is sent by KHBE, unless the enrollee requests an
earlier termination date in accordance with subsection (3) of this
section;
(b) If terminated in
accordance with subsection (4)(b)1. of this section, the last day of the first
month of the three (3) month grace period; or
(c) If terminated in accordance with
subsection (4)(b)2. of this section, in accordance with
KRS
304.17A-245.
(6) For an enrollee who is terminated in
accordance with subsection (4)(e) of this section, the last day of coverage in
an enrollee's prior QHP shall be the day before the effective date of coverage
in the enrollee's new QHP.
(7)
Reasonable notice shall be fourteen (14) calendar days from the requested date
of termination of coverage.
Section
14. Authorized Representative.
(1) An individual may designate an authorized
representative in accordance with
45 C.F.R.
155.227.
(2) An authorized representative shall comply
with state and federal laws regarding:
(a)
Conflict of interest; and
(b)
Confidentiality of information.
(3) An applicant may authorize a
representative to:
(a) Sign an application on
behalf of the applicant;
(b) Submit
an update or respond to a redetermination of eligibility for the applicant in
accordance with Section 7 or 8 of this administrative regulation;
(c) Receive a copy of a notice or
communication from the KHBE;
(d)
Make an appeal request on behalf of an appellant; and
(e) Act on behalf of the individual in a
matter with the KHBE.
(4) An authorization for an authorized
representative shall be valid until:
(a) An
applicant:
1. Changes the authorization;
or
2. Notifies the KHBE and the
authorized representative, through a method described in
45 C.F.R.
155.405(c), that the
authorized representative is no longer authorized to act on behalf of the
individual; or
(b) The
authorized representative informs the KHBE and the individual that the
authorized representative is no longer acting as the authorized
representative.
Section
15. SHOP Employer Eligibility.
(1) An employer shall be a qualified employer
and eligible to purchase coverage through SHOP if the employer meets the
eligibility requirements established in
45 C.F.R.
155.710(b).
(2) An employer shall apply for an
eligibility determination online to participate in SHOP at
www.kynect.ky.gov.
(3) Upon application, an employer shall
provide:
(a) Employer name;
(b) Address of employer location;
(c) A valid federal employer identification
number; and
(d) A statement from
the employer attesting that the employer is:
1. A small employer; and
2. Offering at a minimum, all full-time
employees coverage in a QHP through SHOP.
(4) Except as provided in
45 C.F.R.
147.104(b)(1)(i)(B), a
qualified employer shall meet a minimum group participation rate of fifty (50)
percent, calculated as described in
45 C.F.R.
155.706(b)(10)(i).
(5) A qualified employer may purchase
coverage for its qualified employees at any time during the year.
(6) An employer's plan year shall be the
twelve (12) month period beginning with the effective date of
coverage.
(7) An employer shall
enroll in a QHP or SADP certified by the division by contacting an issuer or a
participating agent.
(8) A
qualified employer who ceases to be a small employer by reason of an increase
in the number of employees shall be eligible to participate in SHOP until the
employer:
(a) Fails to otherwise meet the
eligibility criteria of this section; or
(b) Chooses to no longer purchase health
coverage.
(9) An
employer that fails to meet the requirements in subsection (1) of this section,
shall be denied eligibility to participate in SHOP.
Section 16. SHOP Right to Formal Review.
(1) An employer applicant may request a
formal review of a:
(a) Denial of eligibility
as set forth in Section 15(9) of this administrative regulation; or
(b) Failure of the KHBE to make an
eligibility determination to participate in SHOP within fifteen (15) calendars
days of receiving an application from an employer.
(2) Within ninety (90) days of receipt of a
notice of denial of eligibility, an employer may submit a formal review request
to the division by:
(a) Telephone;
(b) Mail; or
(c) Email.
(3) A formal review request shall clearly
state a reason for the formal review in accordance with subsection (1) of this
section.
(4) If an employer is
notified that a formal review request does not meet the requirements of this
section, the employer may amend the request to satisfy the
requirements.
Section
17. SHOP Dismissal of a Formal Review.
(1) A formal review by an employer shall be
dismissed if the employer:
(a) Withdraws the
formal review request in writing; or
(b) Fails to submit a formal review request
that meets the requirements in Section 16 of this administrative
regulation.
(2) If a
formal review is dismissed in accordance with subsection (1) of this section,
the division shall provide written notice to the employer:
(a) Within three (3) business days of the
dismissal; and
(b) That includes
the reason for dismissal.
(3) The division may reverse a dismissal
under subsection (2) of this section if an employer makes a written request
within thirty (30) days of the date of the notice of dismissal in subsection
(2) of this section and provides new information supporting a reversal of the
previous decision.
Section
18. SHOP Desk Review.
(1) An
employer shall have the opportunity to submit evidence to the division for
review of an eligibility determination.
(2) The division shall consider:
(a) The information used to determine the
employer's eligibility; and
(b) Any
additional evidence provided by the employer under subsection (1) of this
section.
(3) An
applicant's formal review request shall be desk reviewed by one (1) or more
impartial division officials who have not been directly involved in the
eligibility determination implicated in the formal review.
Section 19. SHOP Formal Review Decision.
(1) A desk review by an official of the
division shall result in a final formal review decision.
(2) A final formal review decision shall:
(a) Be in writing;
(b) Be based on the eligibility requirements
in Section 15 of this administrative regulation;
(c) State the decision and the effect of the
decision on the eligibility of the employer;
(d) Summarize the facts relevant to the
formal review;
(e) Identify the
legal and regulatory basis for the decision;
(f) State the effective date of the decision;
and
(g) Be rendered within ninety
(90) days of receipt by the division of an employer formal review
request.
(3) The
division shall issue written notice of the formal review decision to the
employer within ninety (90) days of the date of receipt of a formal review
request.
(4) If the formal review
decision affects the employer's eligibility, the division shall implement the
formal review decision.
Section
20. SHOP Formal Review Record. The formal review record shall be
available and accessible to an employer:
(1)
In a convenient format; and
(2)
During regular business hours, which shall:
(a) Be Monday through Friday from 8:00 a.m.
to 4:30 p.m.; and
(b) Exclude
holidays.
Section
21. Incorporation by Reference.
(1) "Kentucky QHP/APTC Eligibility
Verification Plan", Revised May 2022, is incorporated by reference.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Division of Health
Benefit Exchange, 275 East Main Street 4WE, Frankfort, Kentucky 40621, Monday
through Friday, 8 a.m. to 4:30 p.m., or from its Web site at
www.khbe.ky.gov.
STATUTORY AUTHORITY:
KRS
194A.050(1)